Psychiatria clin. 8: 95 98 (1975)
Sulpiride in School Phobia K. Abe Department of Psychiatry, Osaka City University Medical School, Abenoku, Osaka
Abstract. Sulpiride was administered to 21 children with school phobia. All had shown some depressive symptoms in addition and had been treated by nonpharmacological measures. 13 of them returned to school within a few days and depressive symptoms disappeared eventually (the recovered group). In 3, behaviour at home returned to their premorbid status, but school refusal persisted (the improved group). In the remaining 5, no improvement was observed. In comparison to the present writer’s previous experience with imipramine and benzodiazepines, the response to sulpiride in school-phobic children is more rapid and remarkable.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 11:20:25 AM
For the treatment of school-phobic children, correction of parental attitude is considered important (Hersov, 1972; Takagi, 1973). In Osaka, the first thera peutic measures are usually nonpharmacological and are taken either by a psy chologist, a psychiatrist or a schoolteacher engaged in education of problem children. These specialists examine parental attitude and other characteristics of the family which may have contributed to the problem and give advice to the parents. Among other measures taken are those reminiscent of systematic desen sitization in behaviour therapy: the child is taken by the mother first to the street which leads to the school, then for example, to the gate of the school and eventually to the classroom. From the side of the schoolteachers, various devices are employed to lessen the child’s anxiety at school. However, in spite of these measures, there are a certain proportion of chil dren who continue to show anxiety and somatic symptoms, or are extremely uncooperative with therapeutic measures. In the initial stage, the symptoms are usually alleviated in the afternoon. But if the symptoms progress, the child refuses to leave home and to meet playmates, and he gives up all his previous outdoor activities, becomes weepy, irritable, undertalkative and depressed. In
Abe
96
some, a paranoid tendency in the form of persecutory or pessimistic ideas, complicates the picture: the child expresses his belief that his schoolmates are speaking ill of him, despising or neglecting him, making loud noises or speaking in loud voices to irritate him in the classroom, etc., or that his mother will leave him soon, or his father will not return home from his work. In this stage, the symptoms may not be alleviated towards the evening, and may last for many weeks. For children whose symptoms were not ameliorated by nonpharmacological measures, tricyclic antidepressants had been commonly prescribed in our hospi tal. Since 1969, sulpiride became available in our hospital and it has been used in some of these cases. Sulpiride (Dogmatil, Delagrange —kindly supplied to us by Fujisawa Pharmaceutical Co.) is considered to have a thymoanaleptic, in addi tion to a neuroleptic effect and was found most effective in acute schizophrenia and atypical depression (Borenstein et al, 1968). It was also found effective in children, especially in those with marked ‘inhibition’, school difficulties {Púyelo et al, 1970; Picot et Pinçon, 1970), or phobie anxious symptomatology {Pérez de Francisco, 1972).
Method Altogether 21 children aged 9-17 years - 9 boys and 12 girls - were treated with sulpiride by the present writer at the outpatient department of Osaka City University Hospital. All had received some kind of nonpharmacological measures, i.e., parental counsel ing, desensitization, etc., prior to sulpiride administration. 14 children were brought to the clinic on the mothers’ own initiatives, 4 were referred from school, and 3 were referred by a physician. All had school-phobic symptoms lasting 2-12 weeks at the time of the referral and, in addition to these, some depressive symptoms. Although unpleasant side effects are rare with sulpiride, dystonic reaction had been observed in the past in hospitalized children with daily dosages above 5 mg/kg weight. Therefore, care was taken to employ a daily dosage below this level for school phobia. Capsules containing 50 mg of sulpiride were used. For children of 10-14 years of age two capsules were given as a total daily dose in the morning. For children above or below this age range, the dosage was adjusted by their weight and their initial response to the drug. In all cases the total daily dose was given on awakening before breakfast.
13 of 21 children treated returned to school within a few days and in them anxious, depressive and autonomic symptoms disappeared within a week. In 3 of the remaining children, school phobia persisted, although the accompanying
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 11:20:25 AM
Results
Sulpiride in School Phobia
97
depressive and paranoid symptoms ameliorated and, according to the mothers, behaviour at home returned to nearly normal. The remaining 5 children showed no significant change on sulpiride. Of the 8 children who did not return to school, 6 were subsequently put on imipramine. Thereby, 2 showed further amelioration and returned to school. In the 13 children who recovered on sulpiride, the drug was continued at least 3 weeks after returning to school. In one case, sulpiride had to be continued for 4 months as the relapse appeared imminent on discontinuation.
Discussion The present investigation showed the improvement rate (including partial improvement) to be 76 % on sulpiride (the recovery rate 62 %). Before sulpiride was introduced, the present writer used to employ tricyclic antidepressants, mostly imipramine. The response to imipramine is, in comparison to sulpiride, much less rapid and less clear-cut and in some cases it was difficult to decide whether the improvement was spontaneous or due to medication. It is the pres ent writer’s impression that a larger proportion of school-phobic children respon ded to sulpiride than imipramine. Since early return to school is essential for the child’s subsequent adjustment at school, it is preferable to use drugs which are rapid-acting, like sulpiride. In view of the absence of serious side effects like blood and liver toxicity reported occasionally with imipramine, sulpiride is of first choice, rather than imipramine, if pharmacotherapy is considered necessary. In the present study there were also children who responded to imipramine but not sulpiride. In the USA a favorable effect of imipramine in school phobia was demonstrated by a controlled study (Gittelman-Klein and Klein, 1973). Therefore, imipramine is probably the second-choice drug, if sulpiride is found ineffective.
Borenstein, P.; Cujo, P.; Champion, C. et Olivenstein, C.C.: Etude d’un nouveau psycho trope; le sulpiride (1403 RD). I. Méthode et résultats cliniques. Ann. méd.-psychol. 126: (T.II): 90-99 (1968). Gittelman-Klein, R. and Klein, D.F.: School phobia: diagnostic considerations in the light of imipramine effects. J. nerv. ment. Dis. 156: 199-215 (1973). Hersov, L.: School refusal. Br. med. J. iii: 102-104 (1972). Pérez de Francisco, C.: El sulpiride en psiquiatría infantil. Rev. clin. Cond. 4: 44-47 (1972).
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 11:20:25 AM
References
Abe
98
Kazuhiko Abe, MD. Department of Psychiatry, Osaka City University Medical School, Abenoku, Osaka (Japan)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 11:20:25 AM
Picot, C. et Pinçon, J.A.: Intérêt du sulpiride dans les troubles du comportement de l’enfant. Cah. méd. Lyon. 45: 3393-3396 (1970). Puyelo, R.; Moreau, S. et Miedzyrezecki, J.: Expérimentation du sulpiride en pédo-psychia trie. Sem. Hôp. Paris. 46: 93-96 (1970). Takagi, R.: The family structure of school phobies. Acta paedopsychiat. 39: 131-146 (1973).
Sulpiride in School Phobia K. Abe Department of Psychiatry, Osaka City University Medical School, Abenoku, Osaka
Abstract. Sulpiride was administered to 21 children with school phobia. All had shown some depressive symptoms in addition and had been treated by nonpharmacological measures. 13 of them returned to school within a few days and depressive symptoms disappeared eventually (the recovered group). In 3, behaviour at home returned to their premorbid status, but school refusal persisted (the improved group). In the remaining 5, no improvement was observed. In comparison to the present writer’s previous experience with imipramine and benzodiazepines, the response to sulpiride in school-phobic children is more rapid and remarkable.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 11:20:25 AM
For the treatment of school-phobic children, correction of parental attitude is considered important (Hersov, 1972; Takagi, 1973). In Osaka, the first thera peutic measures are usually nonpharmacological and are taken either by a psy chologist, a psychiatrist or a schoolteacher engaged in education of problem children. These specialists examine parental attitude and other characteristics of the family which may have contributed to the problem and give advice to the parents. Among other measures taken are those reminiscent of systematic desen sitization in behaviour therapy: the child is taken by the mother first to the street which leads to the school, then for example, to the gate of the school and eventually to the classroom. From the side of the schoolteachers, various devices are employed to lessen the child’s anxiety at school. However, in spite of these measures, there are a certain proportion of chil dren who continue to show anxiety and somatic symptoms, or are extremely uncooperative with therapeutic measures. In the initial stage, the symptoms are usually alleviated in the afternoon. But if the symptoms progress, the child refuses to leave home and to meet playmates, and he gives up all his previous outdoor activities, becomes weepy, irritable, undertalkative and depressed. In
Abe
96
some, a paranoid tendency in the form of persecutory or pessimistic ideas, complicates the picture: the child expresses his belief that his schoolmates are speaking ill of him, despising or neglecting him, making loud noises or speaking in loud voices to irritate him in the classroom, etc., or that his mother will leave him soon, or his father will not return home from his work. In this stage, the symptoms may not be alleviated towards the evening, and may last for many weeks. For children whose symptoms were not ameliorated by nonpharmacological measures, tricyclic antidepressants had been commonly prescribed in our hospi tal. Since 1969, sulpiride became available in our hospital and it has been used in some of these cases. Sulpiride (Dogmatil, Delagrange —kindly supplied to us by Fujisawa Pharmaceutical Co.) is considered to have a thymoanaleptic, in addi tion to a neuroleptic effect and was found most effective in acute schizophrenia and atypical depression (Borenstein et al, 1968). It was also found effective in children, especially in those with marked ‘inhibition’, school difficulties {Púyelo et al, 1970; Picot et Pinçon, 1970), or phobie anxious symptomatology {Pérez de Francisco, 1972).
Method Altogether 21 children aged 9-17 years - 9 boys and 12 girls - were treated with sulpiride by the present writer at the outpatient department of Osaka City University Hospital. All had received some kind of nonpharmacological measures, i.e., parental counsel ing, desensitization, etc., prior to sulpiride administration. 14 children were brought to the clinic on the mothers’ own initiatives, 4 were referred from school, and 3 were referred by a physician. All had school-phobic symptoms lasting 2-12 weeks at the time of the referral and, in addition to these, some depressive symptoms. Although unpleasant side effects are rare with sulpiride, dystonic reaction had been observed in the past in hospitalized children with daily dosages above 5 mg/kg weight. Therefore, care was taken to employ a daily dosage below this level for school phobia. Capsules containing 50 mg of sulpiride were used. For children of 10-14 years of age two capsules were given as a total daily dose in the morning. For children above or below this age range, the dosage was adjusted by their weight and their initial response to the drug. In all cases the total daily dose was given on awakening before breakfast.
13 of 21 children treated returned to school within a few days and in them anxious, depressive and autonomic symptoms disappeared within a week. In 3 of the remaining children, school phobia persisted, although the accompanying
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 11:20:25 AM
Results
Sulpiride in School Phobia
97
depressive and paranoid symptoms ameliorated and, according to the mothers, behaviour at home returned to nearly normal. The remaining 5 children showed no significant change on sulpiride. Of the 8 children who did not return to school, 6 were subsequently put on imipramine. Thereby, 2 showed further amelioration and returned to school. In the 13 children who recovered on sulpiride, the drug was continued at least 3 weeks after returning to school. In one case, sulpiride had to be continued for 4 months as the relapse appeared imminent on discontinuation.
Discussion The present investigation showed the improvement rate (including partial improvement) to be 76 % on sulpiride (the recovery rate 62 %). Before sulpiride was introduced, the present writer used to employ tricyclic antidepressants, mostly imipramine. The response to imipramine is, in comparison to sulpiride, much less rapid and less clear-cut and in some cases it was difficult to decide whether the improvement was spontaneous or due to medication. It is the pres ent writer’s impression that a larger proportion of school-phobic children respon ded to sulpiride than imipramine. Since early return to school is essential for the child’s subsequent adjustment at school, it is preferable to use drugs which are rapid-acting, like sulpiride. In view of the absence of serious side effects like blood and liver toxicity reported occasionally with imipramine, sulpiride is of first choice, rather than imipramine, if pharmacotherapy is considered necessary. In the present study there were also children who responded to imipramine but not sulpiride. In the USA a favorable effect of imipramine in school phobia was demonstrated by a controlled study (Gittelman-Klein and Klein, 1973). Therefore, imipramine is probably the second-choice drug, if sulpiride is found ineffective.
Borenstein, P.; Cujo, P.; Champion, C. et Olivenstein, C.C.: Etude d’un nouveau psycho trope; le sulpiride (1403 RD). I. Méthode et résultats cliniques. Ann. méd.-psychol. 126: (T.II): 90-99 (1968). Gittelman-Klein, R. and Klein, D.F.: School phobia: diagnostic considerations in the light of imipramine effects. J. nerv. ment. Dis. 156: 199-215 (1973). Hersov, L.: School refusal. Br. med. J. iii: 102-104 (1972). Pérez de Francisco, C.: El sulpiride en psiquiatría infantil. Rev. clin. Cond. 4: 44-47 (1972).
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 11:20:25 AM
References
Abe
98
Kazuhiko Abe, MD. Department of Psychiatry, Osaka City University Medical School, Abenoku, Osaka (Japan)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/4/2018 11:20:25 AM
Picot, C. et Pinçon, J.A.: Intérêt du sulpiride dans les troubles du comportement de l’enfant. Cah. méd. Lyon. 45: 3393-3396 (1970). Puyelo, R.; Moreau, S. et Miedzyrezecki, J.: Expérimentation du sulpiride en pédo-psychia trie. Sem. Hôp. Paris. 46: 93-96 (1970). Takagi, R.: The family structure of school phobies. Acta paedopsychiat. 39: 131-146 (1973).
